Immunohistochemical analysis of cancer-associated fibroblasts and podoplanin in head and neck cancer.

BACKGROUND: To immunohistochemically evaluate the association between the presence of cancer-associated fibroblasts (CAFs) and the tumour expression of podoplanin (PDPN) in head and neck squamous cell carcinoma (HNSCC) and their association with clinicopathological variables. MATERIAL AND METHODS: A tissue microarray (TMA) with biopsy sections from patients diagnosed with HNSCC was stained with antibodies against the CAFs marker, α-smooth muscle actin (α-SMA), and PDPN. We subsequently evaluated their expression to determine the association between them and with clinicopathological variables including age, primary tumour site, TNM stage, and tumour differentiation grade. RESULTS: Positive reaction to α-SMA was observed in the tumour stroma, revealing spindle-shaped cells compatible with CAFs, which showed a high expression in 62% of cases and a significant association with laryngeal carcinomas, advanced clinical stages, and lower tumour differentiation (P ≤ 0.05). PDPN staining on tumour cells showed low expression in 72% of cases, and it was not associated with any clinicopathological variable or with the presence of CAFs. CONCLUSIONS: The presence of CAFs in the tumour stroma is related to an aggressive phenotype and could increase as the disease progresses, although based on our findings, it would have no relationship, at least directly, with the expression of PDPN.

Transthoracic oesophagectomy with lymphadenectomy in 100 oesophageal cancer patients: multidisciplinary approach.

OBJECTIVES Analysis of the results on the treatment of esophageal cancer by transthoracic esophagectomy by a multidisciplinary team of surgeons and oncologists. METHODS Between January 1990 and December 2009, 100 consecutive patients underwent transthoracic esophagectomy. Data were collected prospectively and clinical, pathological and histological features of the tumors were analyzed as well as the results of postoperative morbidity and mortality. RESULTS The average patient age was 55 years (range 31- 83 years). In 59 cases the tumor was located in the lower third and in 41 cases in the middle third. Forty-six patients had adenocarcinoma and 54 squamous cell carcinoma. In 54 cases radio-chemotherapy was planned preoperatively. Classifi cation according to pathological tumor stage was: stage 0 in 21 patients, stage I in 10 patients, stage IIa in 28, stage IIb in 9, stage III in 21 and stage IV in 11. The mean number of lymph nodes examined was 14 (range 0-28). Hospital mortality occurred in 4 cases and postoperative complications in 29 patients (33%). The most frequent postoperative complication was pulmonary complications in 17 cases. The average hospital stay was 15.2 days (range 10-40 days) CONCLUSIONS The results of esophageal cancer have been improved in recent years due to the formation of multidisciplinary teams in this pathology. In our study we have shown that the results obtained with the transthoracic technique for cancer of the esophagus are within the ranges reported in the literature for teams with high prevalence of the disease.

Are screening serum creatinine levels necessary prior to outpatient CT examinations?

PURPOSE: To determine the percentage of outpatients with elevated serum creatinine levels (>/=2.0 mg/dL [177 micromol/L]) and associated reported risk factors for contrast material-induced nephrotoxic reactions (eg, diabetes, renal disease, male, age >/= 60 years, chemotherapy) who undergo computed tomography (CT) and to define a true high-risk population. MATERIALS AND METHODS: The serum creatinine levels were obtained in a total of 2,034 consecutive outpatients (969 male, 1,065 female) who underwent contrast material-enhanced CT. In addition, selected patient charts were reviewed to determine the presence of risk factors for contrast material-induced nephrotoxic reactions. RESULTS: Only 66 (3.2%) had an elevated serum creatinine level. Risk factors were identified in 64 of the 66 (97%) patients with an elevated serum creatinine level. Renal disease was present in 62 of the 66 (94%) patients. Two of the 66 patients with an elevated creatinine level had no identifiable risk factors, representing 0.1% of the total number of patients. CONCLUSION: The data suggest that the majority of patients with a serum creatinine level of at least 2.0 mg/dL (177 micromol/L) will be identified by screening for risk factors. Careful patient screening, especially for renal disease, at the time of scheduling could result in considerable savings in terms of radiology man-hours expended and laboratory costs.

Operative monitoring of hand and axillary temperature during endoscopic superior thoracic sympathectomy for the treatment of palmar hyperhidrosis.

OBJECTIVE: To find out how much the temperature in the palm rises after upper thoracic sympathectomy for palmar hyperhidrosis, and correlate the temperature with the outcome. DESIGN: Retrospective study. SETTING: University hospital, Spain. SUBJECTS: 73 patients (34 women and 39 men, age range 16-42 years, mean 26) who were operated for palmar hyperhidrosis between 1 January 1995 and 31 December 1997. INTERVENTIONS: Bilateral thoracic endoscopic sympathectomy during which the temperature was monitored on the skin of both axillae and thenar eminences, and in the oesophagus. MAIN OUTCOME MEASURES: Morbidity, alleviation of hyperhidrosis, recurrence rate, and differences in temperature postoperatively. RESULTS: There was minor bleeding during operation in 25 cases (34%), but in only 4 was it sufficient to require insertion of a drain; 2 patients developed transient Homer's syndrome; but the most common complication was compensatory hyperhidrosis (n = 52, 71%). In only 5 was this other than mild and required treatment with aluminium chloride in ethanol 25%. Palmar hyperhidrosis was alleviated in all cases, axillary sweating was considerably improved, and there was improvement in the feet in 56 (77%). There were 5 recurrences, all on the right side, during a mean follow up of 9 months (range 2-36), but in no case was the sweating severe. In almost all cases the temperature of the palm was less than that of the axilla before operation by a mean (SD) of 0.9 (0.3) degrees C. The rise in temperature varied from 1.7 (0.4) degrees C to 2.6 (0.4) degrees C. In the 5 patients who developed recurrences the increase was less (0.5 (0.4) degrees C). CONCLUSION: Thoracic endoscopic sympathectomy is safe, simple, and effective in treating palmar hyperhidrosis that has not responded to conservative treatment. Intradermal monitoring is an accurate and cost-effective way of monitoring temperature during operation. Although it is essential to achieve a rise in temperature of 1 degrees C, our most important finding was that the final temperature in both hands and axillae should be above 35 degrees C and as near as possible to 36 degrees C.

Anatomic variation of extrahepatic biliary tree structures: importance in treatment planning for radiation therapy.

PURPOSE: To demonstrate the variable location of biliary tree components and to assess two treatment planning rules of thumb used for locating porta hepatic nodes for radiation therapy. MATERIALS AND METHODS: The distance of the common hepatic duct bifurcation and duodenal papilla from adjacent vertebral bodies was measured on 34 cholangiograms, and their relationships to particular vertebral body levels were recorded. Adequacy of treatment volume to encompass porta hepatic lymph nodes was evaluated in 30 of these cholangiograms by constructing radiation portals according to the two rules of thumb. RESULTS: Location of the common hepatic duct bifurcation and duodenal papilla varied widely. The treatment portal encompassed 13% (four of 30) of cases when the first rule of thumb was used and 80% (24 of 30) of cases when the second rule of thumb was used. CONCLUSION: The wide variability of location of extrahepatic biliary tree structures suggests the need for individualized treatment planning so that sensitive and dose-limiting healthy tissues can be optimally excluded from radiation treatment portals. Computed tomography and other imaging modalities enable precise location of biliary tree components for radiation treatment planning.

Measurement of coronary artery calcium with dual-slice helical CT compared with coronary angiography: evaluation of CT scoring methods, interobserver variations, and reproducibility.

OBJECTIVE: This study was performed to evaluate new scoring methods for quantitating coronary artery calcifications with helical CT and to compare the results with those of quantitative coronary angiography in patients with suspected coronary artery disease. SUBJECTS AND METHODS: Unenhanced dual-slice helical CT and coronary angiography were performed within 24 hr of each other in 101 patients with symptoms of coronary artery disease. Coronary artery calcifications with a density above 90 H were identified on each slice and, with the same regions of interest, quantitative scoring was performed at thresholds of 90 H (new) 130 H (old). Two mathematical algorithms (one new and one old) were evaluated for both thresholds (yielding four scoring systems). By CT imaging, we defined disease as a score of greater than zero. By angiography, we defined disease as a 50% or greater reduction in the luminal diameter of any major vessel. Interobserver variations in calcification scoring were evaluated. Seventeen of our patients. also underwent a second, consecutive CT scan to determine reproducibility. RESULTS: With the new threshold and the new algorithm, the sensitivity, specificity, and accuracy of helical CT in predicting disease were 88%, 52%, and 76%, respectively. We found a moderate positive association between the total CT calcification score and the number of stenotic coronary arteries at angiography (Pearson's correlation coefficient, .43; p = .05 [analysis of variance]). The accuracy and the area under the receiver operating characteristic curve were higher with the new threshold and the new algorithm. Interobserver agreement in calcification scoring was high (intraclass correlation coefficient, .99 [n = 85]), as was reproducibility (intraclass correlation coefficient, .94 [n = 17]). Reproducibility was higher when scoring was based on the new threshold and the new algorithm. CONCLUSION: The quantity of coronary artery calcifications as measured by helical CT correlated positively with obstructive coronary artery disease as measured by angiography. Interobserver agreement and reproducibility were excellent. A new scoring method showed promise.

Efficacy of supine versus prone biliary lithotripsy: an in vitro study.

Clinical extracorporeal shock wave lithotripsy (ESWL) results have shown that the smaller the gallstone fragments following ESWL, the faster the patient will become stone-free. At ESWL, an attempt is made to produce sand-like fragments that will easily pass through the cystic and common bile ducts. Sixteen pairs of gallstones of equal shape, size, and composition were harvested from cholecystectomy specimens and then fragmented on the Dornier MPL-9000 lithotripter (Dornier Medical Systems, Inc.), individually, in a phantom oriented to duplicate either supine or prone patient positions. The number and size of remaining fragments were compared following the supine versus prone treatments. The 32 stones, ranging from 5-15 mm in diameter, received 1,500 shock waves at 21 kV. Fragments with a maximal diameter of greater than or equal to 4 mm were measured and counted after 750 and 1,500 shock waves. Fragments greater than or equal to 4 mm were found in four out of 16 stones treated supine (25%) and 16 out of 16 stones treated prone (100%). The largest residual fragment regardless of size for each stone pair occurred in the prone group in 14 out of 16 cases (88%). Biliary lithotripsy performed with supine positioning results in more efficacious gallstone fragmentation in this in vitro model; these findings suggest that supine positioning for patients could improve fragmentation and treatment success.

Extracorporeal shock wave lithotripsy of gallstones: results and 6-month follow-up in 141 patients.

A study of biliary shock wave lithotripsy of gallstones sponsored by Dornier Medical Systems, Munich, began in the United States in May 1988 to evaluate the efficacy and safety of extracorporeal shock wave lithotripsy (ESWL) and the need for adjunctive therapy with ursodeoxycholic acid (UDCA). One hundred forty-one symptomatic patients with one to three gallstones 5-30 mm in diameter were randomized to treatment. One week before ESWL, patients were given either UDCA or placebo. This treatment was continued for 6 months. All patients underwent follow-up at predetermined intervals. According to the protocol, re-treatment for fragments larger than 5 mm in diameter could be performed only at 6 weeks; 26 (18%) of the 141 patients were retreated. At 6 months, the stone-free rates for single stones were as follows: patients with noncalcified stones receiving UDCA, 29%; patients with noncalcified stones receiving placebo, 24%; and patients with partially calcified stones receiving either UDCA or placebo, 6%. No significant difference was noted between the UDCA and placebo groups. At 6 months, the stone-free rates in patients with single, noncalcified stones 20 mm or less in diameter were 40% (UDCA) and 32% (placebo), which is superior to rates for those with solitary, noncalcified gallstones 21-30 mm in diameter and those with two or three stones.

Proteolysis of mitochondrial-coded and nuclear-coded proteins found in yeast mitochondria.

The rate of degradation of radioactive labeled mitochondrial proteins synthesized both in vitro and in vivo by isolated yeast mitochondria and growing yeast cells respectively, has been studied. It was found that the in vitro-synthesized mitochondrial proteins are rapidly degraded by an energy-dependent proteolytic system. Under the same experimental conditions the in vivo-synthesized mitochondrial proteins are slowly degraded to a limited extent by a protease which is slightly inhibited by ATP. During this period, the mitochondria are coupled and metabolically active. It is proposed that mitochondria possess an energy-dependent proteolytic system that recognizes as substrates either "abnormal" proteins or unassembled protein subunits encoded in the mitochondrial genome. An apparently different system, which is independent of energy, seems to be responsible for the slow and limited degradation of "normal" mitochondrial proteins.

CT of aortic aneurysms: the distinction between mural and thrombus calcification.

Aortic calcification, either mural or thrombus, is a common finding in patients with abdominal aortic aneurysms. Differentiating between the two sites of calcification is necessary in order to avoid confusing simple thrombus calcification with displaced calcified intima in aortic dissection. The CT scans of 145 cases of abdominal aortic aneurysm and seven cases of abdominal aortic aneurysm with dissection were analyzed with respect to the location of the calcification: mural only or mural and thrombus. Mural calcification was seen in all 152 patients with aneurysms whereas thrombus calcification was identified in only 33 (24%) of the 136 patients with thrombus. Displaced intimal calcification caused by aortic dissection can either appear similar to or, at times, be indistinguishable from thrombus calcification. Thrombus calcification was present in four (57%) of the seven patients with abdominal aortic aneurysms and dissection. To avoid the possibility of a false-positive diagnosis of aortic dissection in patients with abdominal aortic aneurysm, other signs of aortic dissection should be sought such as separation of the true and false lumina by an intimal flap.

Adrenal masses: characterization with T1-weighted MR imaging.

The ability of a T1-weighted spin-echo magnetic resonance (MR) sequence to allow differentiation of benign from malignant adrenal masses at 0.5 T was investigated in 28 patients with 35 adrenal masses. All nine lesions with an adrenal mass-liver signal intensity ratio of 0.71 or less were metastases, and all 15 with a ratio of 0.78 or more were adenomas. Eleven masses (31%)--including six adenomas, three metastases, a pheochromocytoma, and a neuroblastoma--had ratios between these values. Nine of ten masses with adrenal mass-fat intensity ratios of 0.35 or less were metastases, and all 12 with ratios of 0.42 or more were benign. Eleven masses (31%), four malignant and one benign, had ratios between these values. The ratios for two masses could not be calculated due to lack of fat. The specificity of T1-weighted MR imaging in differentiating benign from malignant adrenal masses appears similar to that reported for T2-weighted imaging. However, significant overlap occurred, as has also been reported for T2-weighted imaging. While both imaging sequences may help distinguish benign from malignant adrenal masses in some cases, biopsy is still necessary when an accurate histologic diagnosis is essential.

Focal hepatic lesions: detection by dynamic and delayed computed tomography versus short TE/TR spin echo and fast field echo magnetic resonance imaging.

Eighteen patients with focal hepatic lesions were evaluated with two computed tomographic (CT) techniques including dynamic sequential bolus contrast CT and delayed contrast CT, and 3 magnetic resonance (MR) techniques including a spin echo pulse sequence with TE/TR of 21/310 msec and 2 fast field echo sequences using a TE/TR of 15/300 msec and 80 degrees flip angle (T1-weighted) and TE/TR of 15/500 msec and 10-20 degrees flip angle (T2-weighted). We concluded that CT, using delayed contrast and dynamic sequential bolus contrast techniques, was consistently superior to the 3 MR pulse sequences used on our imagers in terms of number of lesions detected, lesion-to-liver contrast, and quality of scan.

The correlation between MR and angiography in portal hypertension.

Forty-two MR examinations and hepatic panangiograms in 38 patients with portal hypertension were correlated with MR images to determine the ability of MR to detect portal vein hemodynamics. These studies were prospectively analyzed for degree of portal perfusion and direction of flow, portal vein thrombosis, and presence and type of shunt surgery. Thirty-three MR examinations were determined to have grade I (good) or II (fair) portal blood flow. Twenty-nine of these were grade I or II by angiography; the other four were grade IV. Of the eight cases documented as grade IV (hepatofugal portal blood flow) by angiography, none were considered grade IV by MR, suggesting that MR was unable to detect retrograde flow. The other case was not graded because of cavernous transformation of the portal vein. MR correlated well with angiography for the detection or absence of portal vein thrombus, agreeing with angiography in 41 of 42 cases. Two angiographically proven cases of portal vein thrombosis were correctly identified on MR. MR correctly identified the absence of portal vein clot in 39 of 40 angiographically negative cases. MR and angiography also agreed in 41 of 42 cases that a shunt was either present/absent or patent/occluded. The single error was due to inadequate MR scanning in the region of interest. The results show that MR cannot be used to grade blood flow in the portal vein. However, MR accurately detects portal vein thrombosis and the patency of surgical shunts.

Radiographic evaluation of the free jejunal graft.

Jejunal autotransplantation is an increasingly popular method of reconstructive surgery for the upper aerodigestive tract following laryngopharyngectomy. From 1977 to 1985, 55 free jejunal grafts were performed on 49 patients. Thirty patients (61%) experienced reconstructive complications including graft failure in 6, fistula in 18, and strictures in 10. Postoperative dysphagia occurred in 26 patients (53%). The cause of the dysphagia is often complex and related to a number of factors that are discussed. While jejunal autotransplantation is successful in selected patients, complications are not infrequent. The radiologist plays an important role in the evaluation and follow-up of these patients.

Percutaneous aspiration and drainage of pancreatic pseudocysts.

Twenty-five patients with pancreatic pseudocysts had therapeutic intervention procedures that included diagnostic aspiration, short-term drainage (aspiration until completely drained), and long-term catheter drainage. Diagnostic aspirations were used to classify the pseudocysts as infected or noninfected. Short-term drainage was performed on six pseudocysts (two infected and four noninfected) with little success. One resolved and five recurred. Fifteen pseudocysts were treated by long-term catheter drainage. Eight of these (four infected and four noninfected) resolved after initial long-term drainage; two others resolved after additional drainage. The cure rate in these 15 patients was 67%. The other five patients were treated surgically after they had been stabilized but not cured by percutaneous drainage. Complications were few and uniformly minor except for one pneumothorax. Percutaneous aspiration should be used in the diagnosis of pancreatic fluid collections. In noninfected pseudocysts, drainage can be curative. In infected pseudocysts, percutaneous drainage is useful to stabilize the patient and can be either a cure or a temporizing measure until surgery can be performed.

Delayed hepatic CT scanning: increased confidence and improved detection of hepatic metastases.

Fifty oncologic patients with suspected hepatic metastases were prospectively evaluated by dynamic sequential hepatic computed tomography (DSHCT) and by delayed iodine hepatic computed tomography (DICT) scanning. DICT scanning was performed 4-6 hours following administration of 60 g of intravenous iodine. Both techniques were evaluated for lesion definition relative to the adjacent hepatic parenchyma and for numbers of metastases detected. Metastases were detected by both techniques in 26 patients. Fifteen patients (58%) had lesions better defined by DICT. DICT scanning detected more metastases in seven of these 15 patients. In eight patients (31%), there was no difference between the two techniques in numbers of masses detected or lesion definition. In three cases (11%), metastases were more confidently identified on the initial or DSHCT scan. DICT scanning, as described, is useful in defining and detecting hepatic metastases, especially where there is questionable hepatic involvement or better quantification of size is necessary.

Percutaneous needle biopsy in the diagnosis and classification of lymphoma.

Results of percutaneous needle biopsies were evaluated retrospectively in 58 patients in whom a diagnosis of lymphoma was suspected. The biopsy specimen was diagnostic in 94% of the 36 patients with lymphoma, 20 of whom had recurrent disease and 16 of whom had newly diagnosed lymphoma. Sufficient tissue was obtained in 94% of these positive biopsy specimens to allow histologic subtyping of the lymphoma. Immunohistochemical studies performed on seven of the biopsy specimens allowed immunologic subclassification into B-cell and T-cell types of lymphoma. Our results suggest that the percutaneous needle biopsy is a useful and reliable tool in the diagnosis and classification of lymphoma.

Computed tomography of hepatic morphologic changes in cirrhosis of the liver.

Computed tomography of 75 biopsy proven cirrhotic patients was analyzed volumetrically and compared with CT on 50 normal subjects in an attempt to quantitate hepatic morphologic changes specific for cirrhosis. Our data show that the mean percentage of the total liver volume occupied by the right hepatic lobe decreased by 15.2% (p less than 0.0001) and the mean percentage of the total liver volume occupied by the medial segment of the left lobe decreased in volume by 10.9% (p less than 0.09) when compared with normals. Concomitantly, the mean percentage of the total liver volume occupied by the caudate lobe increased by 192% (p less than 0.0001) and the mean percentage of the total liver volume occupied by the lateral segment of the left lobe increased by 55.6% (p less than 0.0001). This increase in the volume of the lateral segment of the left lobe and decrease in the volume of the medial segment of the left lobe have not been described previously. The cirrhotic patients were divided according to etiology of their disease: alcoholic or nonalcoholic. No statistically significant difference was found in the morphologic changes based on etiology when the data were examined using analysis of variants.